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Surgery > Benign Colorectal Disease 1 > Flashcards

Benign Colorectal Disease 1 Flashcards

1
Q

etiology of small bowel ischemia (approach to ddx)

A

arterial occlusion (is afib)

venous occlusion

hypoperfusion/vasoconstriction (i.e ICU patients on inotropes)

non occlusive mesenteric ischemia

obstruction

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2
Q

what is the most common form of bowel ischemia

A

colonic ischemia ..typically in elderly

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3
Q

what % of patients with colonic ischemia develop gangrene

A

15%

watershed areas are the most vulnerable

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4
Q

risk factors for bowel ischemia

A

MI

atherosclerosis

diabetes

medicine induced vasoconstriction (pressors)

aortic instrumentation/surgery

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5
Q

what is indicative of bowel ischemia on physical exam classically

A

pain may be out of proportion to exam

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6
Q

investigations for bowel ischemia

A

CBC lytes Cr lactate

plain xray

CT abdo/pelvis**

CT angio**

**–> go to for evaluating blood vessels of the gut

colonoscopy following acute event–to see the consequences of the ischemia

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7
Q

initial management of bowel ischemia

A

decision is either non operative or operative

non op–> bowel rest, fluids with or without abx, attentive observation if operation not indicated
–> ie if there was an ischemic insult suspected but appear to be improving

operative–>take to the OR if there is perforation, sepsis or suspicion of bowel ischemia with or without necrosis
–> MandM goes up with spillage of bowel contents into abdo cavity

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8
Q

management of arterial occlusion bowel ischemia

A

embolectomy/thrombectomy for revascularization

needs to be done early

may need to be done in concert with bowel resection

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9
Q

management of venous occlusion bowel ischemia

A

anticoag

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10
Q

management of hypoperfusion bowel ischemia

A

rescuscitation and attentive obs

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11
Q

management of obstructive bowel ischemia

A

conservative vs operative depending on extent and length of insult

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12
Q

what is the critical test for bowel ischemia patients?

A

CT angio

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13
Q

approach to bowel ischemia

A

hx
physical
imaging
decide is there peritonitis or is there evidence of compromised bowel? thus do they need surg

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14
Q

define diverticulosis

A

presence of diverticuli on the large bowel

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15
Q

define diverticulitis

A

inflammation of diverticuli on the large bowel

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16
Q

how do the false diverticuli in diverticulosis differ from true diverticuli (like appendix or meckels)

A

false diverticuli do not have the full thickness of the bowel wall like meckels etc. do

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17
Q

in what population are right sided diverticuli more common

A

asian

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18
Q

complications of diverticulosis

A

diverticular bleeding (5-15%)

diverticulitis (5-15%)

complicated diverticulitis (about 25% of those with diverticulitis)

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19
Q

risk factors for diverticulosis

A 
age
obesity
smoking
western diet 
low fibre diet
high fat/red meat
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20
Q

define acute diverticulitis

A

inflammation likely secondary to micro or macro perf of a diverticulum

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21
Q

define complicated diverticulitis

A

abscess

obstruction

fistula–> about 20% of patients following surgical tx of diverticulitis, most commonly involving the bladder (passing particles or air in urine is a sign)

perforation–> often present with peritonitis, sudden if big blow out (but can also present with just a bit of free air)

peritonitis

stricture–> in people who chronically have had this condition; due to cycle of inflammation and resolution

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22
Q

what is the hinchey classification

A

for diverticular disease

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23
Q

hinchey 1

A

most common

phlegmon/small pericolic abscess

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24
Q

hinchey 2

A

often require percutaneous drainage …try and avoid operating

large abscess/fistula

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25
Q

hinchey 3

A

purulent peritonitis/ruptured abscess

pus in the abdomen

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26
Q

hinchey 4

A

feculent peritontis–worst, generally need operation

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27
Q

indication for admission to hospital for diverticulitis

A

inability to tolerate oral intake

significant comorbidities

severe presentation

fail to improve from outpatient management

evidence of significant disease on imaging/sepsis on workup

28
Q

how are most cases of diverticulosis/itis managed

A

by family doc with abx

29
Q

non op management of diverticulitis

A

NPO

IV fluids

IV abx (i.e IV ceftriaxone and metronidazole)

percutaneous drainage of abscess by IR (for larger abscesses)
–> hopefully can be discharged after this

colonoscopy performed after acute episode to rule out an underlying malignancy

30
Q

if someone presents with a suspected ruptured diverticulum what test should you do and what are you ruling out

A

elective colonoscopy to rule out malignancy being the underlying cause

31
Q

indications for emergency surgery to diverticulitis

A

unstable patient

hinchey III-IV

complications–> generalized peritonitis, free air, fistula, obstruction, hemorrhage, abscess

32
Q

can you anatasmose the bowel right away in diverticulitis surgery?

A

no not usually if the surg was urgent… because usually lots of infection and need to make sure everything is all good before reconnecting

usually wait several months to more than a year

33
Q

in what patients can you delay surgery for diverticulitis

A

in those with recurrent bouts… usually not as urgent. can usually do it as an elective procedure and thus prep the bowel and in those cases can often re-anastamose the bowel during the initial surgery

34
Q

define diarrhea

A

3 or more loose/watery stool per day

stool weight more than 200gm/day

35
Q

acute diarrhea ddx

A 
infectious
inflammatory
ischemia
drugs/toxins
metabolic (i.e hyperthyroid)
36
Q

chronic diarrhea ddx

A

IBD
IBS
chronic ischemia bowel
metabolic

37
Q

define acute diarrhea

A

less than 14 days

38
Q

define chronic diarrhea

A

more than 30 days

39
Q

define persistent diarreah

A

more than 30 days

40
Q

what is the most common cause of chronic diarrhea

A

c diff (especially in hospitalized)

41
Q

what is c diff

A

abx associated colitis

42
Q

high risk abx for c diff

A

fluoroquinolones, clinda, cephalosporins, penicillins

43
Q

how do you prevent c diff

A

soap and water is best at preventing transmission as c diff spores are resistant to alcohol based hand sanitizers

44
Q

c diff presentation

A

watery diarrhea 10-15 x per day

lower abdo pain/cramping

can have involvement of small intestine because its an enterocolitis

low grade fever

leukocytosis (i.e white count that shoots up quickly)

pseudomenbranous colitis on colonoscopic exam

may progress to toxic megacolon

45
Q

initial management for non severe c diff

A

oral metronidazole

46
Q

mgmt for severe c diff

A

vanco 125mg PO QID

if no progress–> vanco 500 PO QID for 10-14 days and may add IV metro as adjunct

fidamocicin can be considered in patients with low tolerance to vanco

47
Q

when do you do surgery to c diff

A

severe leukocytosis

significantly elevated lactate

peritoneal signs

severe ileus

toxic megacolon–> OR for total colectomy and ileostomy

48
Q

where is UC found

A

isolated to large bowel, ALWAYS RECTUM

49
Q

where is crohns found

A

any part of GI tract

50
Q

is bleeding more common in crohns or UC

A

UC (90%)

51
Q

is diarrhea more common crohns or UC

A

more common in UC–frequent small stools

52
Q

is abdo pain more common crohns or UC

A

crohns–post prandial/colicky

53
Q

is fever more common crohns or UC

A

crohns (uncommon in UC)

54
Q

is tenesmus more common crohns or UC

A

UC

55
Q

complications of UC

A

strictures, fistulae, perianal disease

56
Q

complications of UC

A

toxic megacolon

57
Q

recurrence of crohn’s vs UC post op

A

common in crohns

no risk post colectomy for UC

58
Q

colon cancer risk in UC vs crohns

A

crohns–> increased if less than 30% of colon involved

UC–> increased except in proctitis

59
Q

lifestyle/diet management of IBD

A

smoking cessation

fluids/electrolyte replacement

60
Q

medical management of IBD

A

anti diarrheal agents

anti inflammatory (5 ASA derivatives)

antibiotics (cipro/flagyll for perianal disease in crohns)

corticosteroids

immunosuppressive meds–> infliximab, adalimumab (humira), methotrexate

61
Q

what is the goal in crohns operation

A

preserve as much bowel as possible which still getting disease out

really you are worried only about gross margins (not microscopic)
–> you know there is a high likelihood of recurrence so may need another surgery so want to preserve bowel

62
Q

indications for crohn’s surgery

A

failure of medical management

complications including fistulae, obstruction, strictures, abscess, perforation, bleeding

63
Q

what type of surgery is the surgery for UC

A

ileal pouch–anal anastamosis on an elective basis

64
Q

crohns post op complications

A

short bowel syndrome

ileal resection less than 100cm–> watery diarrhea

ileal resection more than 100cm–> steattorhea

leaks

strictures

65
Q

what is short bowel syndrome

A

loss or small bowel surface–> increased risk of less than 50% or less than 200cm of functional small bowel

66
Q

post surg complications for total colectomy for UC

A

high output ileostomy

rectal stump inflammation —usually manageable

Surgery (20 decks)

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